Program helps transition patients from hospital room to bedroom

HAZARD — Patients at the Hazard and Whitesburg ARH hospitals who may require more help after they go home now may not have to worry about life after discharge if they qualify for a new transitional care program partnered with the hospitals.

Kentucky Appalachian Transition Services (KATS), an organization owned by Hospice of the Bluegrass, was implemented in February this year and helps qualifying patients adjust to coming back home after a stay in the hospital and makes sure they care for themselves correctly after leaving the hospital, which helps keep patients from having to be readmitted soon after discharge.

“It’s to patients’ benefit to come in the hospital in the acute phase, be treated, and go home, have the rest of their care done at home,” Donna Cox, ARH director of case management, explained. “We need an agency to connect with them once they leave. We can just treat them while they’re in the hospital, with KATS we can partner with them and then that gives them (patients) a little more care once they leave the hospital. It extends the care so you don’t just send them home and them not know anything.”

Gretchen Brown, president and CEO of Hospice of the Bluegrass, said most of the things that cause people to have to return to the hospital are simple fixes, as long as there is someone there to help fix it.

“You get a medicine that you call something like Tylenol, to use a simple example, and then the hospital calls it ibuprofen and may just give you the generic version. When you get home, you may be taking both drugs not knowing that they’re really the same, or that you’re doubling the dose,” Brown said.

Susan Swinford, vice president of administration at Hospice of the Bluegrass and the lead organizer for KATS, explained how KATS got started.

She said the Affordable Care Act, signed in 2010, directed the secretary for the U.S. Department of Health and Human Services to start a test run for community-based transition programs so they could begin implementing them across the country if they worked well. The department offered just over 100 5-year demonstrations beginning in January 2011 to organizations that wanted to pilot a program such as this. KATS submitted its application and was chosen as an organization to do one of these demonstrations.

Since the end of April, the program had admitted 52 patients, with a 9 percent readmission rate for the two months it has been running; they had initially expected a 26 percent readmission rate.

Swinford said at a celebratory luncheon for KATS last week that the program would never have come to fruition had it not been for the dedication of the staff and nurses with KATS.

“Really, this is a celebration of our hard work,” she said.

Swinford said the transition nurses for the program were trained, and continue to be trained, by one of the lead researchers for this type of transitional care, Brian Bixby, who is with the New Court Center for Transitions and Health and the University of Pennsylvania Nursing School. The lead KATS nurse and primary patient screener at the Whitesburg ARH, Jennifer King, said she thinks the KATS program is just what this area needs in terms of after-hospital care.

“I’m the first one in the home to actually assess how things are going, actually to know what’s there and their living situations and what their needs are at home,” King explained.

King, who has been doing home visits since 1994, said this kind of care is important for patients who might not always have the support they tell doctors they will.

“Lots of times in the hospital when you approach patients, when you admit them to the program, they like to paint a wonderful picture of this wonderful support … when in reality when you get out there and you find out the real truth; they have little to no support,” she said.

The program also partners with the Kentucky River Area Development District (KRADD) and all of the programs associated with it, including adult daycare and Meals on Wheels, so that patients in the program can be referred to these services if needed after the patient is through with the program, Swinford said.

“We refer a very large percentage of our patients, probably about 60 percent, to home health and other community resources,” she said.

Peggy Roll, human services director for KRADD, said she is very excited about the improvements to the healthcare system this program can allow by keeping them out of hospital rooms and keeping them healthy where they are most comfortable.

“We want people to be happy, and there’s no place like home,” she said.